| NPI | 1699150219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202785) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10315) |
| Enumeration Date | 2015-07-24 |
| Last Update Date | 2016-04-26 |